High Ankle Sprain

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Summary

High ankle sprains are less common than regular ankle sprains, but when they occur they are often more debilitating. They occur from a twisting injury to the ankle when the foot is planted on the ground. This results in partial tearing of the ligaments that hold the two bones of the lower leg together, at the level of the ankle. Pain and swelling on the outside front part of the ankle are the main symptoms. A marked limp or inability to weight-bear is common initially. Treatment is typically rest and immobilization to allow for healing of the injured ligaments. It will often take many weeks or even months to fully recover from high ankle sprain.

Clinical Presentation

Patients with a high ankle sprain describe an acute twisting injury to the ankle, leading to pain and swelling in the front outside part of the ankle. Unlike a typical ankle sprain, the foot is usually rotated outwardly (externally), typically with the foot planted on the ground. However, a high ankle sprain can also occur in combination with a severe ankle sprain. Pain following a high ankle sprain can be quite localized, and can lead to a marked limp or to the inability to bear weight. These injuries often occur in a sporting event, where there is a sudden change of direction, and an excessive applied force, such as being tackled while playing football. In severe high ankle sprains, there may be generalized ankle swelling and even tenderness on the inside of the ankle.

Physical Examination

On exam, the ankle may demonstrate moderate, to severe swelling after the acute event. Most of this swelling will be centered over the front outside (anterolateral) part of the ankle. Pressing on this area will reveal significant localized tenderness to the front and outside of ankle (figure 1). With time, the swelling will settle, but the point of tenderness may remain. Often, the ankle motion will be restricted, especially with bringing the foot upwards (dorsiflexion). Certain maneuvers or special tests will reproduce or aggravate the symptoms. For example, the squeeze test is performed by squeezing the two bones of the lower legs (tibia and fibula) together, approximately four inches above the ankle joint. This test will tend to reproduce the symptoms in the front, outside part of the ankle in patients who have had a high ankle sprain. The external rotation test involves twisting the foot to the outside, thereby stressing the outer part of the ankle. This will also reproduce symptoms.

Imaging Studies

Plain x-rays of the ankle rarely demonstrate any abnormalities. Occasionally, with a severe high ankle sprain, a stress view (force applied to the heel in an outward direction) will show some displacement and separation of the tibia and fibula (syndesmosis) at the level of the ankle joint, although this is uncommon.

An MRI may demonstrate an injury to the ligament in the outside front part of the ankle, which holds the two bones of the lower leg (tibia and fibula) together (the anterior inferior tibiofibular ligament). This ligament is typically, partially, or entirely disrupted in a high ankle sprain.

Treatment

Non-Operative Treatment

Most high ankle sprains can be treated non-surgically. However, as the ankle joint is required to withstand a fair amount of force with each step, it often takes quite a while to make a full recovery from a high ankle sprain. Non-operative treatment consists of relative immobilization, often in a walker boot, while using crutches. Time then is required to allow the injured ligaments to heal. It’s not uncommon for 6 to 10 weeks or more to be required for satisfactory healing of the ligamentous injury, to reach the point where the individual is able to return to active, unrestricted cutting sports. Taping the ankle may allow an earlier return to activities, albeit with some loss of motion and function. The initial phases of treatment are oriented towards pain control and limiting swelling. This often takes a few weeks to settle. The next phase of recovery is focused on maintaining ankle motion and keeping the muscles of the lower leg firing and active as much as possible. The final phase is a sport specific return to activity, with the use of ankle taping and a graduated return to activity. A focus on proprioceptive exercise is important, particularly in the final phase of rehabilitation.

Surgical Treatment

Occasionally, the ligaments holding the syndesmosis together will be completely or significantly disrupted. In this instance, it may be necessary to reduce the syndesmosis, and stabilize it with screws or some other type of fixation. A direct repair of the syndesmotic ligaments, as well as a cleaning out (debridement) of the ankle joint may be indicated. Fortunately, the vast majority of high ankle sprains do not require surgery.

A certain percentage of patients suffering from a high ankle sprain will have ongoing residual symptoms months after their injury. If this is the case, an investigation (ex. and MRI) to assess for damage to the ankle joint itself (intra-articular injury) should be performed. It’s not uncommon to have an associated anterolateral impingement that stems from a high ankle sprain, leading to scarring of the lower fibers of the anterior, inferior tibio-fibular ligament.


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